17C-172 •
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform. work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of work
location
The Commonwealth of3fassachuse
Department of Indust ACcidents .
Office of Ini
.=.-
600 Washington Street
Boston, MA 02111
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www.mass rwv/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly_
—
Name PusinesS/OrganizatinnfIndivirinal): I kev,;77
-
Address' %W7' .
City/State/Zip: -d 062 Phone. k( '13) 33 -
Are you an employer? Check the appropriatehox: • . •Type of project (required):
•
1.0 I am a employer with 4.. 0 I am a general contractor and I 6. N w .on
have hired the sub-contractors
....loyees (full and/or part-time).*
listed on theattached sheet: 7. ling
2. I am a Sole proprietor or partner-.
ship and have no ealoyees These sub-contractors have -8. D DeMolition .
emiloyees-_nclhave workers' : - • .
working for me m any capacity. 9: '0 - asIdition
10.0 repairs or additions
, 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers haVe*?tercised their .
11.0 PIM:thing repairs or additions
myself [No workers' comp. nght of exemption per MGL .
12. L j zuoofreparrs . •
insurance required t p. 152, § 1(4), and we have no
13.0 ther
employees: [No workers' O
• comp. insitrance neqUired.j. •
*Any applicant that checks box must also fihl out the section below showing theirsvorkers compensation policy information. . .
t Homeownere who submit this affidavit inccating they are doing all work and then hire outside contractors must submit anew affidavit indicating such_
Contractors that check this box mustattached an addtional slzect showing the name of the subcontractors and state whether or notthose-entities have . •
enmloyees. If the sub-contraitorsliave employees, they mustprovide their workers' comp polity number.
I am an employer that is providing workers' co mpensation insurance for my einplayees. Below is the policy and job
information. .
Insurance Company Name: .
•
Policy # or Self-ins Lic. #:
Expiration Date: - •
Job Site Address: : City/State/Zip:' • • • -
Attach a copy of the workers' compensation policy declaration page(showing the policy mangier and expiration date).
. .
Failure to secure coverage: as reqUire d balder Seetibil25A ofMGL c 152 can lead to the Penalties ofa
fine up to $1,500.00 and/or one-year imprisonm* as well as civil penalties m the form of a STOP WORK -ORDER and a fine
of up to $250 00 a day against the violator Be advised that a copy of tlais statement may be forwarded the of
• . 7'77
_ ; and! en7 sor adary Urea the infonnatzo nPravides1
•
I - . 1 i71.-/-7- Dat e; 7/2— • rT
Signature:
Phone 4: ( ) 74:‘ - • • • - • •
Ofiridal use only. Do not write in this area, to be completed by city Or town official
•
City or Town: •• • Permit/License # '
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( ,���' Not Ap
Name of License Holder : ,S "/� t / �-' //n �/7 " /��y [ i vd p ?f y
/ License Number
/ S---- /r'k✓% 17/ r /&/'e4e G1? _ Q /06�Z. / o�..?0 /2 /3
Addres a te
" i (4}Expiration Sign one
.0 Hottiie:lnttirovrement Contract `�, :_Ai :x "11. 3. , .•.T.. No t Applicable ❑
C -�i (2o i sfr�c,4 -t / 6/ 7,6"/
Company Name Registration Number
1 c— PI d✓ ti/d y /2,- F /2 c-e, Cpl, 7 /d6 Z 1(7j2/ 2C/ 2
Address Expirati n Da
Telephone �dZ' X63
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6»
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes I No ❑
I .,.4`.11 .m mO et-3111 , ` n
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) LJ Roofing ❑
Or Doors Pe
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [D] Other [0]
dl leech eethi 1/$ cc* i frl' S, 7 eV'k:.S�YCa+S4, /L°-�fWWei' / Ine/ a 4/4,10// -
Brief Descri tigq of Propose / -
Work: 15144.10470/ .1 =/1 I)<> /tea .S Aver. /+e?/OCik /�1 ft r':U+' 7r /cad n - 6 n'',
(AO
Alteration of existing bedroom Yes ' No Adding new bedroom Yes No �
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
1 Septic Tank City Sewer Private well City water Supply
SECTION 7a -- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f /4ti/'1 7 ' 1/ , as Owner of the subject
property `` / /
hereby authorize !41 ,'/ S
to act on my behalf, in al matters relative to work atitho ed by this building permit application.
./-z-e 772 V2-0/ )
Sign re of Owner Date
(?,- /ceig'v, as Owner /Authorized
Agent hereby declare that the statei6afits and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
_
(
Print Name— VL1/7-0/
Signature f Own gent Date
.
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing , Proposed Required by Zoning
This column to be filled in by q $
Building Department �i
�o. m
Lot Size i i . _
Frontage ` - i 1 i
Setbacks Front
Side Li ` R:; L ' I R:
Rear = = '
Building Height € I r i
Bldg. Square Footage F 1 1% i I
a
Open Space Footage %
(Lot area minus bldg & paved E I
parking)
# of Parking Spaces 1 1 _._.
Fill: 1
(volume & Location)
I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO J DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: I
E. Will the construction activity disturb (clearing, grading, excav ion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
<,p L o i' u -4,4, ate .
` . p , City of Northampton ' ; ' " x
� r ' ` 1 Building Department W •q a ,, � g - � 1 t�
l 212 Main Stteet I i- uv 2 201 r %,,,,,:4,.44''...-,,,-- ' 4 �
Room 1 L ,® �'�,,
\
• rthampton, ' "Z^ 01O -- 4 - � s P � ,
. . , . = -587 -1240 Fax aoyoso �41 P
� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
.* - < � Map Lot - Unit.
Zone Overlay District
Elm St District "` CB. District
SECTION 2 -PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
— 1 -- r_e-e vitt a 11 --e c `-7 2:1 fair g 'E- ,/o, 07 "
t
Name (Print) Current Mailing Address: 0"/060
S- 7 g'73i
I i 1 111 Telephone
Sig -ture
2.2 Authorized Agent: / /�—
6Z S �< 1 Cf`! l / Gt L'rGt r )'- �CJr ' C'e . li t`
Na - i < Current Mailing Address: • Cil'Oe 2—
/. MIL -G , 6 - ` 9 -C ---
Si - - Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
.116' 0 1: i
6. Total = (1 + 2 + 3 + 4 + 5) rg `L- i d • Check Number'
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0219
APPLICANT /CONTACT PERSON C & T CONSTRUCTION
ADDRESS/PHONE 15 Fairway Drive FLORENCE (413) 586 -4965
PROPERTY LOCATION 27 FAIRFIELD AVE
MAP 17C PARCEL 172 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out # 4694 �� � J Fee Paid T /
Typeof Construction: REPLACE KITCHEN CABINETS,COUNTERS,REPLACEMENT
WINDOWS,REMODEL BATH, ADD SHOWER,RELOCATE DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 062884
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
I/' Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
ll
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
27 FAIRFIELD AVE BP- 2013 -0219
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 172 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0219
Project # JS- 2013- 000362
Est. Cost: $23650.00
Fee: $141.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C & T CONSTRUCTION 062884
Lot Size(sq. ft.): 5619.24 Owner: STEIN FREEMAN & WENDY S
Zoning: URB(100)/ Applicant: C & T CONSTRUCTION
AT: 27 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586 -4965
FLORENCEMA01062 ISSUED ON: 8/31/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE KITCHEN
CABINETS,COUNTERS,REPLACEMENT WINDOWS,REMODEL BATH, ADD
SHOWER,RELOCATE DOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/31/2012 0:00:00 $141.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner